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PTSD Can Emerge in POWs, Combat Veterans and Civilians

By Rudi WilliamsAmerican Forces Press Service

WASHINGTON, May 12, 2003  Post Traumatic Stress Disorder, or PTSD, is common in former prisoners of war. But the disorder might not exist in the seven recently returned American soldiers from Iraq, based on their experience.

"This was a relatively short period of captivity," DoD psychiatrist Army Dr. (Lt. Col.) Elspeth Cameron Ritchie said, "and the seven were held together. Historically, if you have colleagues with you, you do a lot better than if you are isolated." She emphasized that she can't discuss more about POWs recently held in Iraq.

"We've learned a lot from POWs from other wars," said Ritchie, program director for DoD on mental health policy and women's issues. "Classically, the first hours or days of capture are scary. You don't know whether you're going to be killed. You're often moved from place to place, and maybe passed from one person to another."

POWs held for a long time are eventually taken to a prison camp, she noted. Prisoners in Korea and Vietnam were held for years in a situation of perhaps chronic malnutrition, torture, maltreatment, or isolation or sensory deprivation, Ritchie noted.

"So when you're looking at what a POW is going to face later on, you want to look at what the captivity experience was," the psychiatrist said. "When POWs are released, there's often a period of elation. Then it can be overwhelming, particularly if the transition is too rapid, from being in a windowless cell to having a thousand microphones stuck in your face."

Consequently, mental health experts take former POWs through what's called a "decompression" stage. During that time, they're given a medical exam and a psychological evaluation to see if they have signs or symptoms of the stress disorder.

"Then we try to prepare them for the media and for all the reunions and homecomings and everything they're going to face," Ritchie noted.

One thing most POWs experience is helplessness and lack of control, the doctor said. She explained that's a bit different from combat veterans, who most of the time had their weapon and their bulletproof jacket and knew what to do.

"As POWs come out of this phase during decompression, they often initially do everything they're told to do," Ritchie said. "Then they begin to assert more independence and start saying, 'No, I'm not going to wear hospital pajamas. I want to eat what I want to eat. I want to go outside and have a cigarette. Get your clipboard out of my face.'"

After the former POWs are evaluated for the acute stress disorder, they'll be followed for at least a year to make sure the PTSD symptoms don't emerge. "If they do, we treat them," Ritchie said.

Some PTSD suffers turn to alcohol and drugs, trying to drown out horrific memories of their traumatic experiences, Ritchie said. "We did see a lot of alcohol and drug abuse in veterans with PTSD following the Vietnam War," she said.

"However, there was also a lot of alcohol and drug abuse while they were in Vietnam. A lot of people were introduced to drugs - heroin and marijuana - there who had never used them before."

"We haven't had the same pattern from other conflicts," the doctor noted. "In the Gulf War I, there has been a much lower amount of PTSD. And we haven't seen the same amount of drug and alcohol abuse. It can certainly happen in some folks, but it hasn't been in the same prevalence as with Vietnam veterans."

Nowadays, post-battle debriefings and other interventions are used to allow combatants to vent and share their emotional reactions before returning to society and their families.

Ritchie said PTSD begins from a feeling of helplessness at the time of a severely traumatic event. She also noted that the disease has three clusters of symptoms - intrusive re-experiencing of the event, numbness or disassociation and hypervigilance. Hypervigilance is described as a feeling like, but not, being on edge all the time.

"The adrenaline just won't turn off," she said.

"We like to break it down into the common immediate effects of trauma, and then the longer-term effects," Ritchie noted. "The longer-term effects we call PTSD. In the immediate effects of trauma from either combat or something like the 9-11 attack, you could have intrusive memories, where the scene plays over and over in your head. You can have feelings of helplessness, fear or hypervigilance."

Ritchie said that she worked with some Pentagon workers after the 9-11 attacks. If some people heard a loud noise from construction equipment, they would jump, thinking that another plane was coming into the Pentagon.

PTSD also might cause changes in family relationships, she noted. "Some people may feel like they're not able to express themselves to their families," Ritchie explained. "They could also have a feeling of disassociation and numbness. If the same effects carry on for a long time, and if they're chronic, that's part of the PTSD picture."

The disorder is either treated with talking therapy or medication, the doctor noted. "One of the talking therapies we use is called cognitive behavioral therapy," said Ritchie.

"It often happens that these people develop distorted thoughts," the doctor continued. For example, she said they might feel guilty because they think that they should have done something to save their colleagues. Or they shouldn't have been taken prisoner of war.

"Distorted thoughts and feelings of guilt can lead to further depression and anxiety," Ritchie emphasized. "So as part of the therapy, we'll try to reframe the distortion: 'You did the best you could. It wasn't your fault that your buddy got killed.'

"We try to help that person realize that, although guilt is fairly common, they shouldn't feel like they failed," she said.

On the other hand, former POWs are often treated as heroes, Ritchie said. But "they may not feel like heroes. This may be a disconnect for them. They're feeling guilty, yet the American public thinks of them as heroic. And we have to help them explain that that's the American public's perception of them and help reconcile those images of themselves."

Whether PTSD suffers have recurring episodes of their traumatic experience throughout their lives depends on the person and the severity of the disorder, Ritchie noted. She added that nightmares and insomnia may also be treated with some very effective medications.

"We know that most people we treat get significantly better," she said. "Some may keep some symptoms for a while. ... The goal would be to get them where the symptoms don't interfere with their functioning."

"We know that most people we treat get significantly better," said psychiatrist Army Dr. (Lt. Col.) Elspeth Cameron Ritchie, program director for DoD on mental health policy and women's issues. Photo by Rudi WilliamsDownload screen-resolutionDownload high-resolution